Problems may arise if:
(1) the formulation of the drug is incompatible with the route
(2) the concentration of the drug is too high
(3) the therapeutic drug level is not achieved
Injection of an oral drug intravenously is the most common type.
Intrathecal injection errors may be the most serious.
Administration of an intravenous formulation orally may go unnoticed if the dosing is correct.
Risk factors:
(1) intensive care, especially when a patient has multiple lines
(2) inexperience
(3) misinterpretation of order (verbal or handwritten order, misuse of an abbreviation)
(4) fixation (oral drug in a syringe is assumed to be for intravenous injection)
(5) lack of controls to prevent wrong route administration (access ports usable by different types of syringes, etc)
(6) error in order
